Equine flexor tendon imaging part 1: Recent developments in ultrasonography, with focus on the superficial digital flexor tendon

Flexor tendon injuries are a major cause of lameness in performance horses and have considerable impact on equine welfare and the wider horse industry. Ageing and repetitive strain frequently cause varying degrees of tendon micro-damage prior to the recognition of clinical tendinopathy. Whilst B-mode ultrasonography is most commonly utilised for detection and monitoring of tendon lesions at the metacarpal/metatarsal level, the emphasis of recent research has focused on the identification of subclinical tendon damage in order to prevent further tendon injury and improve outcomes. The introduction of elastography, acoustoelastography and ultrasound tissue characterisation in the field of equine orthopaedics shows promising results and might find wider use in equine practice as clinical development continues. Based on the substantial number of research studies on tendon imaging published over the past decade this literature review aims to examine the currently used ultrasonographic imaging techniques and their limitations, and to introduce and critically appraise new modalities that could potentially change the clinical approach to equine flexor tendon imaging.

A Preliminary Investigation into Ridden Water Submersion Training as an Adjunct to Current Condition Training Protocols in Performance Horses

Simple Summary

Superficial Digital Flexor Tendon (SDFT) injuries are the most common musculoskeletal injury reported in equestrian jumping disciplines. In an attempt to reduce incidences of injuries in elite event horses, Ridden Water Submersion Training (RWST) is a form of condition training that involves submerging the horse up to sternum height in water and trotting for set intervals. It is used by a small number of trainers to increase cardiovascular fitness whilst potentially minimising tendon temperature increase, which is typically reported during traditional condition training sessions. The results of this study suggest that RWST acted as a moderate sub-maximal intensity level of exercise in a group of elite international event horses whilst preventing the accompanying increase of distal limb temperature commonly associated with condition training on land. RWST could thus be a useful adjunct to current condition training protocols, particularly for horses that compete in disciplines that have high incidence rates of tendon injury. However, further research is required to provide a more comprehensive understanding of the workload imposed during RWST training.

Abstract

This observational study aimed to elucidate the effects of RWST on the cardiovascular and musculoskeletal systems of horses and concurrently determine whether RWST limits distal limb temperature increases previously reported during gallop training on land. A group of 15 clinically sound international event horses were recruited, and heart rate (HR), speed (km/h) and thermal images of the distal limb were analysed at set intervals during RWST training. Intervals of RWST produced a total mean HR_max value of 65.18 ± 3.76%, which is within the parameters for increased aerobic stamina. Mean HR increased significantly (p < 0.01) while mean distal limb temperature decreased significantly (p < 0.01) between warm-up and RWST, which contrasts with positive correlations previously reported during gallop training on land. These preliminary results suggest that RWST can be classed as a moderate submaximal intensity exercise in elite international event horses whilst restricting an increase in temperature of the distal limb that is commonly associated with tendon rupture. Horses competing at very elite levels of eventing only represent a small percentage of the total performance population; therefore, further research is needed to ascertain the physiological effects of RWST in non-elite performance horses, as well as horses competing across various equestrian disciplines.

Microdamage in the equine superficial digital flexor tendon

The forelimb superficial digital flexor tendon (SDFT) is an energy-storing tendon that is highly susceptible to injury during activities such as galloping and jumping, such that it is one of the most commonly reported causes of lameness in the performance horse. This review outlines the biomechanical and biothermal effects of strain on the SDFT and how these contribute to the accumulation of microdamage. The effect of age-related alterations on strain response and subsequent injury risk is also considered. Given that tendon is a slowly healing and poorly regenerative tissue, prompt detection of early stages of pathology in vivo and timely adaptations to training protocols are likely to have a greater outcome than advances in treatment. Early screening tools and detection protocols could subsequently be of benefit in identifying subclinical signs of degeneration during the training programme. This provides an opportunity for preventative strategies to be implemented to minimise incidences of SDFT injury and reduce recovery periods in elite performance horses. Therefore, this review will focus on the modalities available to implement early screening and prevention protocols as opposed to methods to diagnose and treat injuries.

Suspensory Branch Desmitis in a Horse: Ultrasonography, Computed Tomography, Magnetic Resonance Imaging, and Gross Postmortem Findings

Injury of suspensory ligament (SL) branch is a frequently diagnosed problem in horses of different ages and disciplines. This case reports for the first time the ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI) findings in a 10-year-old draught horse with traumatic chronic SL branch desmitis of 8 months duration. The horse had a grade 3 of 5 left hindlimb lameness with a moderately hot, painful, and diffuse swelling from the tarsus till the hoof. Ultrasonography, both SL branches appeared as enlarged hyperechogenic structures with poor demarcation of their margins and massive periligamentous echogenic materials consistent with fibrosis. Computed tomography showed no osseous lesions but did show enlarged, hypodense, and heterogeneous SL branches with an evidence of periligamentar and peritendenious adhesions and air entrapment areas intermingled within fibrous adhesion. Magnetic resonance imaging revealed no abnormal signal intensity received from the proximal part of SL and its body. There were high and intermediate signal intensities received from inflammatory fluid and periligamentar fibrous adhesions, respectively, around SL branches. Both CT and MRI findings were confirmed by gross postmortem examination. In conclusion, CT and MRI are valuable tools for diagnosis of extensive adhesions associated with chronic SL branch desmitis.

Multicentre, blinded, randomised clinical trial comparing the use of flunixin meglumine with firocoxib in horses with small intestinal strangulating obstruction

BACKGROUND

Small intestinal strangulating obstruction (SISO) is associated with endotoxaemia which leads to an increased risk of death. Nonsteroidal anti-inflammatory drugs (NSAIDs) are used to treat signs of endotoxaemia by inhibiting cyclo-oxygenases (COX). COX-1 is expressed constitutively and promotes gut barrier function, whereas COX-2 is inducible and contributes to the signs of endotoxaemia. In preclinical SISO trials, intestinal barrier recovery was more complete with reductions in endotoxin permeability in horses treated with COX-2 selective NSAIDs as compared with horses treated with flunixin meglumine.

OBJECTIVES

We hypothesised that treatment of post-surgical SISO horses with firocoxib (COX-2 selective) would reduce the signs of endotoxaemia to a greater extent than flunixin meglumine (nonselective COX inhibitor) while continuing to provide similar levels of pain control.

STUDY DESIGN

Blinded randomised clinical trial.

METHODS

In addition to clinical monitoring, preoperative and 12-, 24- and 48-h post-operative plasma samples were assessed for prostaglandin E₂ (PGE₂ ), thromboxane B₂ (TXB₂ ), TNF⍺ and soluble CD14 (sCD14).

RESULTS

In 56 recruited SISO horses, either flunixin meglumine (1.1 mg/kg, i.v., q12h) or firocoxib (0.3 mg/kg, i.v. loading dose; 0.1 mg/kg, i.v., q24h) was given in the post-operative period in three university hospitals from 2015 to 2017. COX-2 selectivity was confirmed by a relative lack of inhibition of the COX-1 prostanoid TXB₂ by firocoxib and significant inhibition by flunixin meglumine (P = 0.014). Both drugs inhibited the COX-2 prostanoid PGE₂ . There were no significant differences in pain scores between groups (P = 0.2). However, there was a 3.23-fold increased risk (P = 0.04) of increased plasma sCD14 in horses treated with flunixin meglumine, a validated biomarker of equine endotoxaemia.

MAIN LIMITATIONS

Horses were all treated with flunixin meglumine prior to referral. In addition, many horses were treated with lidocaine, which has been shown to mitigate the deleterious effects of flunixin meglumine.

CONCLUSIONS

In SISO cases, firocoxib reduced a biomarker of endotoxaemia as compared with flunixin meglumine while continuing to provide similar levels of pain control.